Relapse PreventionRelapse Prevention

G. Alan Marlatt, Ph.D.

University of WashingtonAddictive Behaviors Research Center

abrc@u.washington.edu http://depts.washington.edu/abrc

Contemporary Approaches to Contemporary Approaches to Substance Abuse TreatmentSubstance Abuse Treatment

12-Steps Fellowships - AA, Al-Anon, ACOA, NA, CoDA, SLAA Traditional Minnesota Model Inpatient Treatment - Detox,

medical supervision, disease model, AA, group, drug education Intensive Outpatient Minnesota Model Treatment - Medical

supervision, individual sessions, disease model, AA, groups Therapeutic Communities for Substance Abuse - 24-hour

residential setting, norms, responsibility, encounter groups Pharmacological Therapy – Antabuse, methadone, LAMM,

buprenorphine, naltrexone, etc Psychological Therapies – Group, couple, and individual

therapy Behavior Therapy – Aversion therapy, cue exposure, skills

training, contingency management, community reinforcerment Cognitive-Behavioral Therapy – Relapse Prevention, coping

skills training, cognitive therapy, lifestyle modification

Brickman’s Model of Helping & Coping Applied to Addictive

Behaviors

Is the person

responsiblefor the

development

of theaddictive behavior?

Is the person responsible forchanging the addictive behavior?

YES

NO

COMPENSATORY MODEL

(Cognitive-Behavioral)

Relapse = Mistake, Error, or Temporary Setback

YES NO

MORAL MODEL(War on Drugs)

Relapse = Crime or Lack of Willpower

SPIRITUAL MODEL(AA & 12-Steps)

Relapse = Sin or Loss of Contact with Higher Power

DISEASE MODEL(Heredity & Physiology)

Relapse = Reactivation of the Progressive Disease

Marlatt’s Top Ten Reasons Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Why Alcoholism is NOT a

DiseaseDisease# 10Drinking is a risk behavior, not a disease.

Both drinking and smoking can become addictive behaviors – and a leading cause of potentially fatal diseases, such as cirrhosis and cancer.

Marlatt’s Top Ten Reasons Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Why Alcoholism is NOT a

DiseaseDisease# 9 Unlike biological disease, alcoholism can be

eliminated or arrested by a voluntary decision made by the drinker.

# 10 Drinking is a risk behavior, not a disease. Both drinking and smoking can become addictive behaviors – and a leading cause of potentially fatal diseases, such as cirrhosis and cancer.

Marlatt’s Top Ten Reasons Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Why Alcoholism is NOT a

DiseaseDisease# 8 There is no official medical diagnosis of

“Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV).

# 9 Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker.

# 10 Drinking is a risk behavior, not a disease. Both drinking and smoking can become addictive behaviors – and a leading cause of potentially fatal diseases, such as cirrhosis and cancer.

Marlatt’s Top Ten Reasons Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Why Alcoholism is NOT a

DiseaseDisease# 7 There is no known single biological or

genetic cause of alcoholism (The “Alcoholism Gene” Theory has not been replicated).

# 8 There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV).

# 9 Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker.

# 10 Drinking is a risk behavior, not a disease. Both drinking and smoking can become addictive behaviors – and a leading cause of potentially fatal diseases, such as cirrhosis and cancer.

Marlatt’s Top Ten Reasons Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Why Alcoholism is NOT a

DiseaseDisease# 6 Effective treatments for alcoholism are

almost always based on psychosocial, cognitive-behavioral, or spiritual self-help groups, not ‘Medical Treatment’ (Antabuse or Naltrexone).# 7 There is no known single biological or genetic cause of alcoholism (The “Alcoholism Gene” Theory has not been replicated).

# 8 There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV).

# 9 Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker.

# 10 Drinking is a risk behavior, not a disease. Both drinking and smoking can become addictive behaviors – and a leading cause of potentially fatal diseases, such as cirrhosis and cancer.

Marlatt’s Top Ten Reasons Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Why Alcoholism is NOT a

DiseaseDisease# 5 Unlike with most diseases, many people

resolve alcohol problems on their own without treatment (e.g. maturing out, spontaneous remission).# 6 Effective treatments for alcoholism are almost always based on psychosocial, cognitive-behavioral, or spiritual self-help groups, not ‘Medical Treatment’ (Antabuse or Naltrexone).

# 7 There is no known single biological or genetic cause of alcoholism (The “Alcoholism Gene” Theory has not been replicated).

# 8 There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV).

# 9 Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker.

# 10 Drinking is a risk behavior, not a disease. Both drinking and smoking can become addictive behaviors – and a leading cause of potentially fatal diseases, such as cirrhosis and cancer.

Marlatt’s Top Ten Reasons Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Why Alcoholism is NOT a

DiseaseDisease# 4 Loss of control drinking in alcoholics is

triggered more by psychological factors (expectancy) than by the biological effects of alcohol.# 5 Unlike with most diseases, many people resolve alcohol problems on their own without treatment (e.g. maturing out, spontaneous remission).

# 6 Effective treatments for alcoholism are almost always based on psychosocial, cognitive-behavioral, or spiritual self-help groups, not ‘Medical Treatment’ (Antabuse or Naltrexone).

# 7 There is no known single biological or genetic cause of alcoholism (The “Alcoholism Gene” Theory has not been replicated).

# 8 There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV).

# 9 Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker.

# 10 Drinking is a risk behavior, not a disease. Both drinking and smoking can become addictive behaviors – and a leading cause of potentially fatal diseases, such as cirrhosis and cancer.

Marlatt’s Top Ten Reasons Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Why Alcoholism is NOT a

DiseaseDisease# 3 Belief in the disease model of alcoholism

predicts greater relapse in a recent prospective treatment outcome study (Univ. of New Mexico) funded by NIAAA.

# 4 Loss of control drinking in alcoholics is triggered more by psychological factors (expectancy) than by the biological effects of alcohol.

# 5 Unlike with most diseases, many people resolve alcohol problems on their own without treatment (e.g. maturing out, spontaneous remission).

# 6 Effective treatments for alcoholism are almost always based on psychosocial, cognitive-behavioral, or spiritual self-help groups, not ‘Medical Treatment’ (Antabuse or Naltrexone).

# 7 There is no known single biological or genetic cause of alcoholism (The “Alcoholism Gene” Theory has not been replicated).

# 8 There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV).

# 9 Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker.

# 10 Drinking is a risk behavior, not a disease. Both drinking and smoking can become addictive behaviors – and a leading cause of potentially fatal diseases, such as cirrhosis and cancer.

Marlatt’s Top Ten Reasons Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Why Alcoholism is NOT a

DiseaseDisease# 2 The ‘Father’ of the disease model of

alcoholism, Benjamin Rush, M.D., supported a continuum model of drinking, including moderate drinking (Temperance = Moderation, not Abstinence)# 3 Belief in the disease model of alcoholism predicts greater relapse in a recent prospective treatment outcome study (Univ. of New Mexico) funded by NIAAA.

# 4 Loss of control drinking in alcoholics is triggered more by psychological factors (expectancy) than by the biological effects of alcohol.

# 5 Unlike with most diseases, many people resolve alcohol problems on their own without treatment (e.g. maturing out, spontaneous remission).

# 6 Effective treatments for alcoholism are almost always based on psychosocial, cognitive-behavioral, or spiritual self-help groups, not ‘Medical Treatment’ (Antabuse or Naltrexone).

# 7 There is no known single biological or genetic cause of alcoholism (The “Alcoholism Gene” Theory has not been replicated).

# 8 There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV).

# 9 Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker.

# 10 Drinking is a risk behavior, not a disease. Both drinking and smoking can become addictive behaviors – and a leading cause of potentially fatal diseases, such as cirrhosis and cancer.

Marlatt’s Top Ten Reasons Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Why Alcoholism is NOT a

DiseaseDisease

… and the #1 reasonwhy alcoholism

is NOT a disease …

Marlatt’s Top Ten Reasons Marlatt’s Top Ten Reasons Why Alcoholism is NOT a Why Alcoholism is NOT a

DiseaseDisease# 1 If alcoholism is not a disease, what is it? It

is an Addictive Behavior (with multiple biopsycho-social causes and consequences) that increases the risk of physical disease (i.e. cirrhosis)# 2 The ‘Father’ of the disease model of alcoholism, Benjamin Rush, M.D., supported a continuum model of drinking, including moderate drinking (Temperance = Moderation, not Abstinence)

# 3 Belief in the disease model of alcoholism predicts greater relapse in a recent prospective treatment outcome study (Univ. of New Mexico) funded by NIAAA.

# 4 Loss of control drinking in alcoholics is triggered more by psychological factors (expectancy) than by the biological effects of alcohol.

# 5 Unlike with most diseases, many people resolve alcohol problems on their own without treatment (e.g. maturing out, spontaneous remission).

# 6 Effective treatments for alcoholism are almost always based on psychosocial, cognitive-behavioral, or spiritual self-help groups, not ‘Medical Treatment’ (Antabuse or Naltrexone).

# 7 There is no known single biological or genetic cause of alcoholism (The “Alcoholism Gene” Theory has not been replicated).

# 8 There is no official medical diagnosis of “Alcoholism,” only degrees of alcohol abuse and alcohol dependence (DSM-IV).

# 9 Unlike biological disease, alcoholism can be eliminated or arrested by a voluntary decision made by the drinker.

# 10 Drinking is a risk behavior, not a disease. Both drinking and smoking can become addictive behaviors – and a leading cause of potentially fatal diseases, such as cirrhosis and cancer.

Biopsychosocial Factors in Development and Maintenance of

Addictive BehaviorsBIOLOGICAL FACTORS

Biological vulnerability and genetic predisposition in interaction with certain facilitating environments create problems and eventually disease.

Pharmacological impact of excessive use of alcohol and other drugs on body chemistry, physiology , and the organ systems of the body.

Tolerance – Increased frequency of use and higher doses over time.

Withdrawal – Negative effects of cessation of addictive behaviors.

Higher risk of developing specific physical disorders (diseases) associated with the chronic and excessive use of particular substances.

Biopsychosocial Factors in Development and Maintenance of

Addictive BehaviorsPSYCHOLOGICAL FACTORS

Motivation – Stages of habit initiation and stages of habit change.

Expectancies – Positive outcomes of drug use and self-efficacy.

Attributions – Effects of substance use and reasons for relapse.

Sensation-Seeking – Excessive need for stimulation Impulsivity – Inability to effectively control or restrain

behavior. Negative Affect – Dysphoric moods such as anxiety &

depression. Poor Coping – Deficits in cognitive and behavioral skills or

inhibitions in the ability to perform behaviors due to the effects of anxiety.

Biopsychosocial Factors in Biopsychosocial Factors in Development and Maintenance of Development and Maintenance of

Addictive BehaviorsAddictive BehaviorsSOCIOCULTURAL FACTORS

Family History – Dysfunctional family settings especially parental alcohol and drug problems and parental abuse or neglect of children.

Peer Influences – Social pressure to engage in risk-taking behaviors including substance use especially when related to gang membership.

Culture and Ethnic Background – Norms and religious beliefs that govern the use of alcohol and drugs and ethnic variations the body’s rate and efficiency of metabolizing drugs and alcohol.

Media/Advertising – Societal emphasis on immediate gratification and glorification of the effects of alcohol and drug use.

Analysis of High-Risk Situations for Relapse Alcoholics, Smokers, and Heroin Addicts

RELAPSE SITUATION (Risk Factor)

Alcoholics (N=70)

Smokers (N=35)

Heroin Addicts (N=32)

TOTAL Sample (N=137)

Negative Emotional States 38% 43% 28% 37%

Negative Physical States 3% - 9% 4%

Positive Emotional States - 8% 16% 6%

Testing Personal Control 9% - - 4%

Urges and Temptations 11% 6% - 8%

TOTAL 61% 57% 53% 59%

Interpersonal Conflict 18% 12% 13% 15%

Social Pressure 18% 25% 34% 24%

Positive Emotional States 3% 6% - 3%

TOTAL 39% 43% 47% 42%

INTRAPERSONAL DETERMINANTS

INTERPERSONAL DETERMINANTS

“Let’s just go in and see what happens.”

Analysis of High-Risk Situations for RelapseAlcoholics, Smokers, Heroin Addicts, Compulsive Gamblers, and

OvereatersRELAPSE SITUATION (Risk Factor)

Alcoholics (N=70)

Smokers (N=64)

Heroin Addicts (N=129)

Gamblers (N=29)

Overeaters (N=29)

TOTAL Sample (N=311)

Negative Emotional States 38% 37% 19% 47% 33% 35%

Negative Physical States 3% 2% 9% - - 3%

Positive Emotional States - 6% 10% - 5% 4%

Testing Personal Control 9% - 2% 16% - 5%

Urges and Temptations 11% 5% 5% 16% 10% 9%

TOTAL 61% 50% 45% 79% 48% 56%

Interpersonal Conflict 18% 15% 14% 16% 14% 16%

Social Pressure 18% 32% 36% 5% 10% 20%

Positive Emotional States 3% 3% 5% - 28% 8%

TOTAL 39% 50% 55% 21% 52% 44%

INTRAPERSONAL DETERMINANTS

INTERPERSONAL DETERMINANTS

High-Risk Situation

Effective coping response

Increased self-efficacy

Decreased probability of

relapse

Ineffective coping response

Lapse (initial use of the

substance)

Increased probability of

relapse

Abstinence Violation Effect

¤ Perceived effects of the substance

Decreased Self-efficacy

¤ Positive outcome

Expectancies (for initial effects of

the substance)

A Cognitive Behavioral Model of

the Relapse Process

Relapse Prevention: Specific Intervention Strategies

High-Risk Situation

Abstinence Violation Effect

Ineffective Coping

Response

Lapse

Decreased Self-Efficacy

¤ Positive Outcome

Expectancies

Self-Monitoring ¤

Inventory of Drug-Taking Situations

¤ Drug Taking Confidence

Questionnaire

Mediation, Relaxation Training, Stress Management

¤ Efficacy-Enhancing

Imagery

Contract to limit extent of use

¤ Reminder Card (what to do if you have slip)

Description of Past Relapses

¤ Relapse Fantasies

Situational Competency Test

¤ Coping-Skill

Training ¤

Education about immediate vs. delayed effects

¤ Decision Matrix

Cognitive Restructuring

(a lapse is a mistake: coping vs.

Skill-Training with Alcoholics:

One- Year Follow-Up Results

0

20

40

60

Skill training Combined Controls

p < .05

SD = 6.9

SD = 62.2

(Mean = 5.1) (Mean = 44.0)

Days of Continuous Drinking

Skill-Training with Skill-Training with Alcoholics: Alcoholics:

One- Year Follow-Up ResultsOne- Year Follow-Up Results

0

500

1000

1500

2000

Skill training Combined Controls

p < .05

SD = 2218.4SD = 2218.4

SD = 507.8

(Mean = 399.8) (Mean = 1592.8)

Number of Drinks Consumed

Skill-Training with Skill-Training with Alcoholics: Alcoholics:

One- Year Follow-Up ResultsOne- Year Follow-Up Results

0

20

40

60

80

Skill training Combined Controls

p < .05

SD = 17.8

SD = 17.8

(Mean = 11.1) (Mean = 64.0)

Days Drunk

Skill-Training with Skill-Training with Alcoholics: Alcoholics:

One- Year Follow-Up ResultsOne- Year Follow-Up Results

0

2

4

6

Skill training Combined Controls

SD = 17.8

SD = 2.6SD = 2.6

P = N.S.

Controlled Drinking

(Mean = 4.9) (Mean = 1.2)

RELAPSE PREVENTIONEmpirical Support for the RP

ModelNarrative Review of 24 Randomized Controlled Trials

Kathleen M. Carroll (1996)1. While RP usually does not prevent a lapse better than

other active treatments, RP is more effective at “Relapse Management,” i.e. delaying the first lapse longer and reducing the duration and intensity of lapses that do occur before abstinence is regained.

2. RP is particularly effective at maintaining treatment effects over long-term follow-up measurements of one to two years or more.

3. RP treatment outcomes often demonstrate “delayed emergence effects” in which greater improvement in coping occurs over time.

4. RP may be most effective for “more impaired substance abusers including those with more severe levels of substance abuse, greater levels of negative affect, and greater perceived deficits in coping skills.” (Carroll, 1996, p.52)

RELAPSE PREVENTIONEmpirical Support for the RP Model

Meta-Analysis Review of 17 Controlled StudiesIrvin, Bowers, Dunn & Wang (1999)

Irvin, Bowers, Dunn, & Wang (1999) selected 17 controlled studies to evaluate the overall effectiveness of the RP model as a substance abuse treatment and to statistically identify moderator variables that may reliably impact the outcome of RP treatment. In their discussion, they conclude that their “Results indicate that RP is highly effective for both alcohol-use and substance-use disorders” (p.3)

RELAPSE PREVENTIONEmpirical Support for the RP

ModelMeta-Analysis Review of 17 Controlled Studies

Irvin, Bowers, Dunn, & Wang (1999)

Moderator Variables with Significant Impact on RP Effectiveness

1. Group therapy formats were more effective than individual therapy formats.

2. RP is more effective as a “stand alone” than as aftercare.3. Inpatient settings yielded better treatment outcomes

than outpatient settings.4. Stronger treatment effects on self-reported use than on

physiological measures.5. While RP was effective across all categories of substance

use disorders, stronger treatment effects were found for substance abuse than alcohol abuse.

The “Black and White” Model of Relapse

Abstinence

Relapse

Thin Line

The The Abstinence Violation Violation EffectEffect

Emotional- guilt, blame, failure, etc.

Cognitive- Internal, stable,global, uncontrollable

Self-awareness increaseComparison to Internalized

Standards- greater difference, more guilt

Behavioral Reaction- dominant habitual response

Cognitive Reaction- resolve discrepancy

Relapse PreventionSpecific Intervention Strategies

What to do if a lapse occurs Stop, Look, and Listen Keep Calm Renew Your Commitment Implement your Relapse

Prevention plan Ask For Help Review the situation leading-up to

the lapse

RELAPSE PREVENTIONSpecific Intervention Strategies

Coping with Lapses(Initial Use of a Substance)

Relapse Plan with Emergency Procedures

Relapse Contract to limit extent of use Relapse Reminder Card “What do I do in case of a lapse?”

POSITIVE

Improved self-efficacy, confidence

and esteem; family approval;

better health; financial gains;

continued success

Enhanced ability to control one’s life;

more money; more respect;

greater popularity

Frustration; denial of pleasure; anger at

oneself for not doing

what one wants

Denial of immediate

and seemingly easy

gratification

Immediate reduction of

anxiety; revenge against one’s spouse; better

feeling about work; immediate gratification

Feeling as though one is

caught in a fog, so one

doesn’t have to deal with

reality

Feeling that one has

lost control; anger at family and employer; financial loss;

weakness

Continued deterioration; loss of one’s family; loss of

one’s employment; poor health;

loss of friends; greater self-hatred

Delayed Consequences

ALCOHOL ABSTINENCE ALCOHOL USE

Immediate Consequences Immediate Consequences

Delayed Consequences

NEGATIVE NEGATIVE POSITIVE POSITIVE

Decision Matrix

Precontemplation Stage

Contemplation Stage

Preparation Stage

Action Stage

Maintenance Stage

Relapse Stage

Motivational Enhancement

Strategies Assessment & Treatment

Matching

Relapse Prevention & Relapse

Management

Stages of Change in Substance Abuse & Dependence: Intervention

Strategies

Thank You.Thank You.